Anxiety Symptoms in Diabetes Scale in Adolescents (ASDS-A)

Abstract

The Anxiety Symptoms in Diabetes Scale in Adolescents (ASDS-A) is a psychometrically validated self-report instrument developed to evaluate diabetes-specific anxiety symptoms in youth diagnosed with Type 1 diabetes (T1D). Conceptualized and validated by Kaitlyn Rechenberg, Laura Szalacha, and Andrew Bugajski in 2023, the instrument addresses a critical diagnostic and developmental gap at the intersection of pediatric endocrinology and clinical adolescent psychology. Although generic instruments evaluate generalized distress or panic manifestations, they routinely fail to capture the idiosyncratic clinical fears intrinsic to juvenile diabetes management, including fear of severe hypoglycemia, nocturnal seizure phobia, peer stigmatization, regimen-related embarrassment, and relational distress regarding parental burden. The ASDS-A was derived from qualitative explorations of lived experiences among adolescents aged 12 to 16 years, generating an initial item pool of 50 candidate questions that underwent rigorous content validation by clinical nurse specialists and pediatric psychologists, narrowing the instrument to 15 items. Subsequent psychometric testing using principal component analysis (PCA) identified a robust single-factor structure accounting for 43.61% of total variance. The removal of one item due to a sub-threshold loading (.287) established the final 14-item operational scale. The instrument demonstrates high internal consistency (Cronbach's alpha = .896) and solid concurrent and convergent validity against established instruments, including the Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-2 (PHQ-2), and the Pediatric Quality of Life Inventory 3.0 Diabetes Module (PedsQL 3.0). Completable within 5 to 10 minutes, the ASDS-A provides clinicians, behavioral health professionals, and pediatric researchers with a targeted psychometric tool for early screening, tracking psychological barriers to self-management, and informing tailored psychoeducational and cognitive-behavioral interventions.

Keywords

Adolescents, Anxiety Symptoms in Diabetes Scale in Adolescents, ASDS-A, Type 1 Diabetes, Diabetes-Specific Anxiety, Hypoglycemia Phobia, Pediatric Psychology, Psychometrics, Self-Management, Pediatric Quality of Life

Authors

The Anxiety Symptoms in Diabetes Scale in Adolescents was developed through a clinical and academic collaboration spanning pediatric nursing science, behavioral medicine, and biostatistics:

• Kaitlyn Rechenberg, PhD, CRNP, CPNP-PC: College of Nursing, University of South Florida, Tampa, Florida, United States. Correspondence Address: University of South Florida, 12901 Bruce B. Downs Blvd, MDC 22, Tampa, FL 33612. Email: [email protected].
• Laura Szalacha, EdD, MS: College of Nursing, University of South Florida, Tampa, Florida, United States. ORCID: 0000-0002-4504-6980.
• Andrew Bugajski, PhD, RN: Department of Research and Sponsored Studies, Lakeland Regional Health, Lakeland, Florida, United States.

Purpose

Managing Type 1 diabetes requires constant daily vigilance. Adolescents must continuously calculate carbohydrate ratios, administer subcutaneous insulin via multi-dose injections or continuous subcutaneous insulin infusion (insulin pumps), monitor continuous glucose monitoring (CGM) sensors, and anticipate metabolic fluctuations driven by exercise, hormonal surges, and stress. Adolescence is simultaneously marked by rapid neurodevelopmental reorganization, increasing autonomy from caregivers, expanding reliance on peer approval, and heightened susceptibility to self-consciousness. Within this sensitive developmental stage, chronic illness management frequently provokes distress that diverges substantially from standard anxiety pathology.

The primary purpose of the ASDS-A is to provide a brief, standardized, self-report instrument tailored to identify, quantify, and monitor diabetes-specific anxiety in pediatric patients aged 12 to 16 years. Traditional psychometric instruments, such as the State-Trait Anxiety Inventory (STAI) or the Generalized Anxiety Disorder-7 (GAD-7), focus on free-floating apprehension, non-specific somatic reactivity (e.g., muscle tension, generalized autonomic arousal), or generalized catastrophic cognitions. While these generic metrics detect generalized emotional distress, they fail to capture the specific cognitive, somatic, and behavioral anxieties tied to diabetes care, such as fear of nocturnal hypoglycemic comas, shame over medical devices, purposeful permissive hyperglycemia, or guilt regarding family financial and emotional strain.

Conversely, broad condition-related instruments like the Problem Areas in Diabetes (PAID) scale or the Diabetes Distress Scale (DDS) target overall emotional burden and regimen burnout rather than the explicit affective and somatic symptoms of clinical anxiety. Furthermore, existing anxiety scales specialized for diabetes—such as the Hypoglycemia Fear Survey (HFS)—isolate hypoglycemia avoidance while omitting social stigmatization, device embarrassment, and the somatic mimicry between anxiety attacks and insulin reactions. The ASDS-A fills this empirical gap by capturing the multi-determined spectrum of adolescent diabetes distress, functioning both in research contexts as a sensitive outcome metric and in routine clinical pediatric endocrinology as an actionable triage screener.

Psychological Construct

The psychological construct evaluated by the ASDS-A is diabetes-specific anxiety in youth. Rather than representing a generalized neurotic trait, this construct captures situational anxiety, somatic hyperarousal, and avoidant coping behaviors directly elicited by the chronic demands, physical threats, and social repercussions of living with Type 1 diabetes. Across its theoretical development and factor analytic validation, the ASDS-A assesses four core psychological dimensions:

1. Somatic Hyperarousal and Symptom Overlap

Adolescents with T1D face a unique diagnostic dilemma: the neuroglycopenic and autonomic symptoms of acute hypoglycemia—such as diaphoresis, resting tachycardia, tremulousness, dizziness, and nausea—closely mimic the autonomic activation seen during panic attacks and generalized autonomic hyperarousal. Items such as "When I am afraid, I feel like I might throw up" and "When I am afraid it is difficult to breathe" assess somatic distress triggered by fear. Somatic fear can induce anticipatory anxiety, leading youth to misattribute benign anxiety sensations to falling blood glucose levels, prompting unnecessary carbohydrate ingestion and rebound hyperglycemia.

2. Social Stigmatization and Regimen-Induced Embarrassment

Adolescence is defined by peer conformity and sensitivity to social surveillance. The overt paraphernalia of modern diabetes care (e.g., automated insulin delivery pumps, CGM alarms, glucose finger-stick lancets, glucagon delivery devices) can single out adolescents in public or academic settings. The ASDS-A evaluates social evaluation fears through items like "I am embarrassed when I have to leave class to manage my diabetes," "I am embarrassed by my insulin pump," and "People judge me because I have diabetes." This social anxiety often leads to intentional non-adherence, such as silencing critical alarms or delaying insulin administration until the adolescent is out of peer view.

3. Fear of Hypoglycemia and Maladaptive Compensatory Behaviors

Severe hypoglycemia is an acute, life-threatening metabolic emergency that can induce seizures, loss of consciousness, and cognitive incapacitation. The psychological trauma of prior hypoglycemic episodes often fosters intense fear, particularly during unsupervised periods or sleep (e.g., "I worry a lot about my blood sugar getting too low" and "I worry a lot about my blood sugar getting too low while I'm sleeping"). To avoid low blood sugar, youth may engage in maladaptive compensatory behaviors. Notably, the scale captures intentional permissive hyperglycemia: "I keep my blood sugar high on purpose when I'm out with my friends." This clinical behavior trades long-term vascular health to gain acute psychological relief from the fear of public collapse.

4. Relational and Caregiver Distress

Parent-adolescent conflict around blood glucose management is well documented. However, the ASDS-A captures a less recognized emotional dimension: adolescent guilt and empathy regarding family burden. Items such as "I worry about my mom because it's stressful to have a teenager with diabetes" and "I worry about my dad because it's stressful to have a teenager with diabetes" assess parentification, internalized responsibility, and relational distress. Adolescents often internalize family stress, occasionally hiding management struggles to avoid burdening their parents.

Theoretical Framework

The ASDS-A is rooted in several converging psychological models: Lazarus and Folkman's Transactional Model of Stress and Coping, Beck's Cognitive Theory of Anxiety, and developmental systems models of pediatric chronic illness management.

Under the Transactional Model of Stress and Coping (Lazarus & Folkman, 1984), psychological stress depends on primary cognitive appraisal (evaluating a stressor as a threat, challenge, or harm) and secondary appraisal (evaluating one's coping resources). For adolescents with T1D, everyday events—such as school sports, exams, or dining out—are continually appraised through the lens of metabolic risk. When secondary appraisals identify personal and social resources as insufficient to manage potential hypoglycemia or public embarrassment, the cognitive system triggers acute anxiety.

This stress appraisal directly guides coping strategies. Problem-focused coping, such as checking blood glucose or adjusting basal rates, can be disrupted if the adolescent relies on emotion-focused, maladaptive avoidance. Intentional under-dosing or maintaining elevated blood glucose levels functions as avoidant emotion-focused coping: it eliminates the short-term threat of acute hypoglycemia, but at the expense of chronic hyperglycemia and elevated glycated hemoglobin (HbA1c).

Complementing stress-coping theory, Beck's cognitive model explains how threat-related cognitive distortions generate behavioral distress. In adolescents with diabetes, automatic thoughts frequently center on physical vulnerability ("If I go low in class, everyone will see me pass out") and perceived negative social evaluation ("People think I caused this illness"). These cognitive distortions activate physiological responses that closely mimic hypoglycemia, reinforcing a vicious cycle of autonomic arousal, catastrophizing, and behavioral avoidance.

Validity

The psychometric validation of the ASDS-A demonstrated solid content, construct, and concurrent criterion validity across rigorous testing phases:

Content and Face Validity

The instrument was built through qualitative developmental research with adolescents aged 12 to 16 with T1D. This qualitative base provided ecological validity by using language, idioms, and emotional descriptions directly voiced by youth. An initial 50-item pool was scrutinized by an expert panel of pediatric endocrinologists, certified diabetes care and education specialists, and clinical child psychologists. Items were evaluated for clinical relevance, developmental appropriateness, linguistic clarity, and absence of semantic ambiguity. This review refined the measure down to 15 targeted candidate items prior to field administration.

Concurrent and Convergent Validity

Concurrent validity was established by comparing the ASDS-A against nine established psychometric instruments spanning general anxiety, depression, diabetes-specific quality of life, and treatment adherence in adolescents with T1D:

• General Anxiety: Assessed using the Generalized Anxiety Disorder-7 (GAD-7; Spitzer et al., 2006). The ASDS-A demonstrated a significant, moderate-to-strong positive correlation (r = .493, p < .001). This confirms that while the ASDS-A captures general distress, it remains distinct from broad generalized anxiety, preserving its specificity to diabetes-related situations.
• Depressive Symptomatology: Assessed using the Patient Health Questionnaire-2 (PHQ-2; Richardson et al., 2010). A statistically significant positive correlation was identified (r = .510, p < .001), consistent with extensive pediatric literature documenting high comorbidity between chronic illness distress and depressive symptoms.
• Pediatric Quality of Life Inventory 3.0 Diabetes Module (PedsQL 3.0; Varni et al., 2003): The ASDS-A correlated significantly with all major functional and disease subscales:
  • Diabetes Symptoms Subscale: r = −.581, p < .001 (higher diabetes-specific anxiety correlates with a greater burden of physical symptoms).
  • Treatment Barriers Subscale: r = −.595, p < .001 (increased anxiety is strongly tied to perceived obstacles in completing regimen requirements).
  • Treatment Adherence Subscale: r = −.536, p < .001 (higher anxiety scores correspond with lower adherence to complex diabetes self-care).
  • Worry Subscale: r = −.694, p < .001 (very strong inverse correlation demonstrating convergent validity against generalized diabetes-related worry).
  • Communication Subscale: r = −.660, p < .001 (greater anxiety is tied to poorer communication with healthcare providers and family members).
  • PedsQL 3.0 Total Scale: A notable correlation of r = .655 (p < .001) confirms that elevated diabetes anxiety is directly tied to lower overall health-related quality of life.

Reliability

The ASDS-A shows high internal consistency across empirical evaluations:

• Cronbach's Alpha (α): In the primary validation sample of adolescents aged 12 to 16 years, the overall scale achieved a Cronbach's alpha of .896. This exceeds the conventional .80 standard for research tools and approaches the .90 benchmark recommended for individual clinical screening.
• Item-Total Correlations: Item analysis indicated that candidate items loaded reliably onto the primary construct. When Item 14 ("I don't worry about my diabetes too much") was evaluated, its low item-total correlation and low loading (.287) confirmed that its removal improved measurement precision. The remaining 14 items demonstrated strong inter-item correlations, confirming construct homogeneity without problematic item redundancy.
• Measurement Precision: The high internal consistency supports calculating a small standard error of measurement (SEM), providing reliable tracking of individual symptom changes over time during clinical interventions.

Factor Analysis

The structural dimensionality of the ASDS-A was examined using Principal Component Analysis (PCA) to evaluate whether diabetes anxiety in youth reflects a general overarching construct or distinct independent components:

Extraction and Component Structure

Initial component extraction revealed two components with eigenvalues exceeding Kaiser's criterion of 1.0. However, comparison of the extracted eigenvalues revealed a clear dominant primary component:

• Component 1 Eigenvalue: 6.106
• Component 2 Eigenvalue: 1.410

The eigenvalue of the first component was more than 4.3 times larger than that of the second component. Visual examination of the Scree plot showed a sharp break ("elbow") following the first component, confirming the presence of a single dominant underlying dimension. This dominant primary component accounted for 43.61% of the total variance across items.

Item Loadings and Scale Truncation

Item loadings across the primary component were examined using a retention threshold of .30 to .40. Fourteen of the fifteen items loaded heavily on this single component (most ranging from .45 to .78). However, Item 14 ("I don't worry about my diabetes too much") yielded an inadequate loading of .287. Because this loading fell below accepted empirical standards, Item 14 was eliminated, establishing the final 14-item operational version of the ASDS-A. The resulting unidimensional structure confirms that calculating a composite total score is psychometrically sound for both clinical screening and research.

Instrument / Measurement Tool

• Instrument Name: Anxiety Symptoms in Diabetes Scale in Adolescents (ASDS-A)
• Test Type: Standardized, disease-specific self-report rating scale
• Target Population: Adolescents aged 12 to 16 years diagnosed with Type 1 Diabetes (T1D); applicable in pediatric endocrinology clinics, research settings, and clinical psychology services
• Administration Format: Paper-and-pencil questionnaire or electronic self-administered questionnaire (tablet, computer, patient portal)
• Administration Time: Approximately 5 to 10 minutes (maximum 15 minutes)
• Item Count: 14 operational items in the final scale (derived from a 15-item candidate pool)
• Response Scale: 5-point Likert-type rating format:
  • 1 = Strongly Disagree
  • 2 = Disagree
  • 3 = Neither Agree nor Disagree
  • 4 = Agree
  • 5 = Strongly Agree
• Scoring Procedures:
  • Positively worded items indicating anxiety symptoms are scored directly from 1 to 5.
  • Reverse-coded items (such as Item 11, Item 12, Item 13, and Item 15 depending on final scoring protocols) are inverted prior to summation (1 = 5, 2 = 4, 3 = 3, 4 = 2, 5 = 1).
  • Item 14 is dropped from operational composite scoring due to its low factor loading (.287).
  • Scores are summed to produce an overall continuous diabetes-specific anxiety score. Higher aggregate scores indicate greater levels of diabetes-specific anxiety and higher risk for adherence difficulties and psychosocial distress.

Permissions & Fee and Test Year

The Anxiety Symptoms in Diabetes Scale in Adolescents (ASDS-A) was developed and validated in 2023 by Kaitlyn Rechenberg, Laura Szalacha, and Andrew Bugajski, published in Children's Health Care.

• Fee: Free for non-commercial academic research, educational use, and non-profit clinical screening.
• Commercial Use: Commercial licensing, inclusion in proprietary digital health applications, and use within funded pharmaceutical trials requires written permission from the copyright holders and the publisher.
• Permissions Contact: Prospective investigators should contact the corresponding author, Dr. Kaitlyn Rechenberg, at the University of South Florida College of Nursing ([email protected]), or request reuse rights directly through the publisher (Taylor & Francis / Informa UK Limited).

References

• Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer Publishing Company.
• Rechenberg, K., Szalacha, L., & Bugajski, A. (2023). A self-report measure of diabetes-specific anxiety symptoms for adolescents. Children's Health Care, 52(2), 123–137. https://doi.org/10.1080/02739615.2022.2047970
• Richardson, L. P., Rockhill, C., McCauley, E., Grossman, D. C., Boonstra, C. A., & Katon, W. (2010). Evaluation of the PHQ-2 as a brief screen for detecting major depression among adolescents. Pediatrics, 126(5), 1098–1103. https://doi.org/10.1542/peds.2010-0852
• Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097. https://doi.org/10.1001/archinte.166.10.1092
• Varni, J. W., Burwinkle, T. M., Jacobs, J. R., Gottschalk, M., Kaufman, F., & Jones, K. L. (2003). The PedsQL in type 1 and type 2 diabetes: Reliability and validity of the Pediatric Quality of Life Inventory Generic Core Scales and Type 1 Diabetes Module. Diabetes Care, 26(3), 631–637. https://doi.org/10.2337/diacare.26.3.631

13. Items of the Scale (Questionnaire)