Summary

Although the Preschool Age Psychiatric Assessment is a semi-structured inter- view developed specifically to assess psychiatric disorders in two- to five-year-old children, to date it has not been used extensively in studies evaluating treatment of preschool anxiety disorders.

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Innovative Assessment Approaches for Young Anxious Children

3.1 Anxiety-Specific Screening Tools for Four- to Seven-Year-Old Children

3.1.1 Preschool Screen for Child Anxiety Related Emotional Disorders

The Preschool Screen for Child Anxiety Related Emotional Disorders (Pre- SCARED) is a new parent report and screening tool developed by our group to screen and identify anxiety symptoms in four- to seven-year-old children (Appendix 3.1). It is derived, with permission, from the parent version of the Screen for Child Anxiety Related Emotional Disorders (SCARED; Birmaher, Khetarpal, Brent, Cully, Balach, Kaufman, & Neer,1997), which is a 41-item questionnaire for parents of children nine years and older (a child version that could be completed by children nine years and older is also available). The parent and child versions of the SCARED have sound psychometric properties, as established by several studies (e.g., Birmaher et al.,1997; Birmaher, Brent, Chiappetta, Bridge, Monga, & Baugher,1999; Monga, Birmaher, Chiappetta, Brent, Kaufman, Bridge, & Cully,2000).

The new, Pre-SCARED parent questionnaire consists of 50 items. Some items on the Pre-SCARED were taken from the SCARED and reworded in order to capture what behavior parents might observe in their young children rather than what par- ents might infer. For example, an item taken from the SCARED, ‘When my child feels frightened it is hard for him/her to breathe’ was reworded (as many parents reported not knowing if their children were having difficulty breathing or not) to become, ‘When my child is frightened or scared, I notice that it is hard for him/her to breathe and/or he/she breathes rapidly.’ Additionally, some items were taken from the SCARED and reworded to be more developmentally appropriate for four- to seven- year-old children. For example, the SCARED item, ‘My child gets stomachaches when he/she is at school’ became the Pre-SCARED item, ‘My child gets stom-

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achaches when he/she is at school, daycare, or other organized activities’ (as some parents of preschoolers did not answer the original SCARED question because their preschool aged children were not in school yet). Other items on the Pre-SCARED are new items, not included in, or reworded from the original SCARED. An example of a new item on the Pre-SCARED is, ‘My child speaks to teachers or other caregivers when needed.’ Sixteen (32%) of the current 50 items making up the Pre-SCARED were taken directly from the SCARED without modification (and with permission of the SCARED developers), 18 (36%) items were taken from the SCARED and reworded (also with permission from the SCARED creators and as described above) to be more reflective of presenting symptoms in younger children, and 16 (32%) items not found on the SCARED were newly generated.

A stepwise approach using input from clinicians experienced in preschool anxiety disorders and input from 77 parents of five- to seven-year-old children diagnosed with an anxiety disorder who completed the original parent SCARED at several time points as part of their participation in a comparative study of the Taming Sneaky Fears program (Monga, Rosenbloom, Tanha, Owens, & Young,2015), determined which items would make up the Pre-SCARED. In the first step, items repeatedly left blank (without response), or which caused confusion (e.g., parents would ask the research coordinator how they should respond) on the original parent SCARED, were identified and discarded. In the second step, 25 (33%) of the 77 parents provided specific and detailed feedback as to which items from the SCARED they felt were relevant (or applied to their anxious five- to seven-year-old children), and which were not. In the third step, experienced clinicians provided their impressions as to whether the items from the original SCARED that were retained in the Pre-SCARED were relevant anxiety symptoms for young children and were appropriately worded (or reworded) for parents of younger children. In the fourth step, as our goal was to generate about 50 items for the Pre-SCARED, clinicians experienced in preschool anxiety disorders generated new items for inclusion in the Pre-SCARED, targeting anxiety symptoms that were not already included on the Pre-SCARED; consensus among the experienced clinicians yielded several new items pertaining to social anxiety and selective mutism. In the fifth and final step, parent feedback about the original SCARED not providing enough choices of responses (with the SCARED three-point rating scale), guided the decision to use a five-point scale (0 never, 1almost never, 2sometimes, 3almost always, and 4always). Appendix 3.1provides the 50 items from the Pre-SCARED. As with the SCARED, the Pre- SCARED yields one total score, which is derived from a total summation of the rating scores on each of the 50 items.

Efforts to validate the new Pre-SCARED to aid in the screening of young chil- dren presenting with symptoms or concerns of anxiety are ongoing. Early evidence suggests that this 50-item screen is internally consistent, with Cronbach’sα0.94, based on Pre-SCARED data obtained from 224 parents of four- to seven-year-old children (Mage5.6 years;SD1.1; 102 males) presenting to our clinic for a new psychiatric assessment (67% were given an anxiety disorder diagnosis, 19% were given a non-anxiety disorder diagnosis, 13% were not given any psychiatric diagno- sis). A subsample (N 113) completed both the Pre-SCARED and the Preschool

Anxiety Scale (Spence & Rapee,1999), which, as discussed in Chap.2, is a widely used screening tool used with parents of young children. The correlation between the Pre-SCARED total score and the Preschool Anxiety Scale total score wasr0.81, p < 0.001, suggesting convergent validity of the Pre-SCARED with the Preschool Anxiety Scale.

Further evaluation of the psychometric properties of the Pre-SCARED is currently under way.

3.2 Tools to Assess Selective Mutism and Social Anxiety Disorder

As described in Chap.2, there are currently few well-validated, user-friendly instru- ments to reliably assess symptoms of anxiety in four- to seven-year-old children, and even fewer well-validated, user-friendly tools available to reliably assess selec- tive mutism and/or social anxiety disorder in this age group. As part of a recently completed data collection phase of a randomized control trial comparing the efficacy of two group interventions in the treatment of four- to seven-year-old children with selective mutism and/or social anxiety disorder and their parents (N94;Mage 5.44 years;SD1.0; 28 males) (Sect.5.3.5), our research group developed four novel instruments to assist clinicians and researchers in the assessment of these conditions.

These novel assessment tools include the Mutism Accommodation Scale, the Talk- ing Behavior Assessment Tool, the Selective Mutism Versus Social Anxiety Disorder Criteria Checklist and the Steps to Talking. Preliminary data regarding these novel tools show promise in both the clinical and research assessments of four- to seven- year-old children presenting with the symptom of ‘not speaking’ or possible selective mutism and/or social anxiety disorder. These assessment tools and their suggested use in the assessment process are discussed below. As most of these assessment tools were recently developed, extensive psychometric evaluation is pending. Whenever relevant and feasible, preliminary results regarding psychometric properties of these instruments are provided.

3.2.1 Mutism Accommodation Scale

The Mutism Accommodation Scale (Appendix3.2) is a 22-item parent questionnaire that was developed on the premise that parents and caregivers could unintentionally accommodate their children’s mutism in order to alleviate their children’s distress.

For example, parents of children with selective mutism may speak or allow others to speak for their children, allow or facilitate non-verbal communication instead of verbal communication, and even allow their children to avoid distressing situations in which speech is expected. In children with non-specific anxiety disorders, such

forms of accommodation have been associated with increased symptom severity, lower levels of functioning, and poorer outcomes (Thompson-Hollands, Kerns, Pin- cus, & Comer,2014). Although not studied previously in selective mutism, parental accommodation may have a contributory role in the development and maintenance of selective mutism. As such, the items for the Mutism Accommodation Scale were generated based upon other scales of accommodation that have been used in various psychiatric disorders such as obsessive-compulsive disorder. Our hypothesis is that parental accommodation would decrease as the children’s selective mutism improves with treatment. This is a hypothesis that has partial support based on preliminary evidence with parents who completed the Taming Sneaky Fears Cog- nitive Behavior Therapy program (Chaps.5–11), which encourages parents to set a clear expectation for speech and supportively push their children past their fear of being seen and heard speaking by Climbing Bravery Ladders for speaking (gradual exposure or progressive desensitization; see Chap.10for further details). However, an equally valid hypothesis is that a decrease in parental accommodation would result in an improvement in child’s speaking behavior. As part of our randomized control trial (data collection recently completed), all parents completed the Mutism Accommodation Scale at all assessment time points (Sect.5.3.5). Data analyses are underway and we plan to examine the question of what comes first, a reduction in parental accommodation or an improvement in the child’s speaking behavior.

3.2.2 Talking Behavior Assessment Tool

The Talking Behavior Assessment Tool (Appendix3.3) is a clinician-administered tool that was developed as an interview guide for clinicians and researchers when conducting assessment interviews with parents of four- to seven-year-old children who present with the symptom of ‘not speaking’ or who are referred for possible selective mutism and/or social anxiety disorder.

As seen in Appendix3.3, the Talking Behavior Assessment Tool inquires about the number and variety of languages spoken at home, the child’s comfort level with different languages (if applicable), as well as whether parents note concerns with their child’s speech and language skills. Additionally, the Talking Behavior Assess- ment Tool inquires about the child’s speaking behavior and level of verbal interaction in a variety of settings (e.g., home, daycare, school, and community). As clinicians or researchers interview the parents, a checkmark indicating the child’s best perfor- mance in each specific setting or situation or with each specific individual is noted.

Such a tool provides a detailed, structured, and consistent approach when asking about a child’s speaking behaviors in a variety of settings. The Talking Behavior Assessment Tool is currently used in our clinic on a regular basis. It is used primarily for descriptive and qualitative purposes.

3.2.3 Selective Mutism Versus Social Anxiety Disorder Criteria Checklist

As discussed in Chap.1, the extant literature on anxiety disorders documents the high comorbidity of selective mutism and social anxiety disorder. As reviewed in Chap.2, there are few standardized tools that currently exist to assess the specific symptoms characterizing selective mutism. Because of this high comorbidity and the lack of validated measures to assess selective mutism, it is often difficult to distin- guish between the symptoms that characterize selective mutism and social anxiety disorder and thus difficult to untangle which is the primary diagnosis when a young child presents with the symptom of ‘not speaking.’ Our research group developed the Selective Mutism Versus Social Anxiety Criteria Checklist (Appendix3.4) for clinicians and researchers to use during a clinical assessment to evaluate whether the child’s symptom of ‘not speaking’ reflects a primary diagnosis of selective mutism, social anxiety disorder, or both.

The Selective Mutism Versus Social Anxiety Criteria Checklist consists of two subscales, a selective mutism subscale and a social anxiety disorder subscale, each of which includes three items that capture the core features or characteristics of each disorder. After completing a clinical assessment and interview with the child who is a potential research subject and/or presents in clinic with the symptom of ‘not speaking,’ the clinician or researcher uses a four-point scale (0don’t know/not sure; 1false or no; 2variable; and 3true or yes) to rate each of the six items on the checklist. The score for each subscale ranges from 0 to 9. The first item for each subscale (item 1 and item 4) focuses on the ‘warm up’ time required for a child to speak in school or other social settings. Clinicians and researchers keep in mind that when evaluating young children who are not speaking at school with teachers, it is necessary to consider the child’s age and the time of the school year when the assessment is taking place. For example, if a child presenting for an assessment in March has not been speaking to the teacher since the beginning of the school year in September, a diagnosis of selective mutism is likely (assuming that other psychiatric diagnoses have been ruled out as explanations for not speaking). Conversely, a child presenting for an assessment in October (shortly after the start of the school year) could have either social anxiety disorder or selective mutism as it is yet unclear whether the child might ‘warm up’ and begin to speak if given enough ‘warm up’

time.

Items 2 and 3 of the Selective Mutism Versus Social Anxiety Criteria Checklist (selective mutism subscale) focus on the observations that many children with a pri- mary diagnosis of selective mutism are able to interact in a more normative fashion if they are not required to speak. Items 5 and 6 on the Selective Mutism Versus Social Anxiety Criteria Checklist (social anxiety disorder subscale) focus on the obser- vations that children with a primary diagnosis of social anxiety disorder typically demonstrate self-consciousness (e.g., worries about embarrassment or being judged) and physical signs of tension, which typically would not be seen in children with

‘pure’ selective mutism.

Clinical experience with the Selective Mutism Versus Social Anxiety Criteria Checklist suggests that if a clinician rates most of items 1–3 as ‘true/yes or variable’

and most of items 4–6 as ‘false/no,’ the child is likely to have a primary diagnosis of selective mutism. Conversely, if a clinician rates most of items 4–6 as ‘true/yes or variable’ and most of items 1–3 as ‘false/no,’ the child is likely to have a primary diagnosis of social anxiety disorder. Children receiving high scores on all six items of the Selective Mutism Versus Social Anxiety Criteria Checklist likely have co-morbid selective mutism and social anxiety disorder requiring the clinician to evaluate which is the primary diagnosis based upon the use of other tools and clinical judgment.

Both the Selective Mutism Versus Social Anxiety Criteria Checklist and the Anxi- ety Disorders Interview Schedule Parent version (Silverman & Albano,1996), a well- validated semi-structured interview used for diagnostic purposes in many preschool anxiety research trials (as discussed in Chap.2), were completed in a sample of four- to seven-year-old children (N84;Mage5.83 years;SD1.11; 25 males) attend- ing our clinic for an assessment of selective mutism and/or social anxiety disorder.

Using Spearman correlations, the selective mutism subscale of the Selective Mutism Versus Social Anxiety Criteria Checklist correlated significantly with the Anxiety Disorders Interview Schedule Parent version—Clinician Severity Rating for selec- tive mutism (rs0.52,p< 0.001), while the social anxiety disorder subscale of the Selective Mutism Versus Social Anxiety Criteria Checklist correlated significantly with the Anxiety Disorders Interview Schedule Parent version—Clinician Severity Rating for social anxiety disorder (rs0.43,p< 0.001). These findings provide pre- liminary convergent validity of the Selective Mutism Versus Social Anxiety Criteria Checklist.

Clinical experience and preliminary data provide some support that the Selec- tive Mutism Versus Social Anxiety Criteria Checklist could assist clinicians and researchers in distinguishing between a diagnosis of selective mutism and social anxiety disorder, or establishing co-morbidity of the two diagnoses in young chil- dren who present with a symptom of not speaking. Further validation and exploration of the psychometric properties of this tool are warranted and are currently underway.

3.2.4 Steps to Talking

The Steps to Talking (Appendix3.5) is a novel clinician-administered instrument that can be used by clinicians and researchers in the assessment of four- to seven- year-old children presenting for ‘not speaking’ or possible selective mutism and/or social anxiety disorder. The Steps to Talking quantify a child’s nonverbal and ver- bal communication with an assessor during an encounter. The level of nonverbal and verbal interaction is measured at three time points during a clinical encounter:

(1) immediately upon greeting; (2) within the first 30 minutes of the encounter; and